Provider Demographics
NPI:1699273532
Name:FERNANDEZ, MARLENE (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, MPAS
Mailing Address - Street 1:92 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:407-649-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9111302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101035100Medicaid